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-,FOR OFFICE USE: FOR OFFICE USE: <br /> APPLICATION FOR SANITATION PERMIT <br /> i (Complete in Triplicate) Permit No. ..-...'_.____a D <br /> --------------�•--•----•..------ ----._.- -------•----- Date lssued_..1�.`_+I_� <br /> --- This Permit Expires 1 Year From Date Issued <br /> Application is hereby made to.the San Joaquin Local Health District for a permit to construct and install the work herein described, <br /> ' This application is made in compliance with County Ordinance No. 549 and existing Rules and Regulations; <br /> a <br /> JOB ADDRESS/LOCATION. ._/.- _....__..._ , 1 R _.--K. -----------------------CENSUS TRACT_----.----­------------- ------- <br /> Owner's Name • a l ---------------- -------------Phone................................... <br /> Address. ----- ------ ......-- -FZip--.: --- ------------ ---------- CitY- kA ---.-- .............. <br /> Contractor's Name....... -------- a�. .�_L�_ - - License #, - - 6:.�6c�r- Phone�-SF_�9r�l- . . <br /> Installation will serve: ResidenceApartment House E] Commercial ❑ Trailer Court E]k <br /> Eel ❑ ``Z.Other----- ......... ..... . . .............. <br /> i Number of living units:- .�----,--„--Number of bedrooms_ ..Garbage Grinder............Lot Size...... Q..-. -. ; <br /> Water Supply: Public System and name.-...,.. ------------------ - - ............................................... :,.._.__.Private <br /> Character of soil to a depth of 3 feet: [Sand C] Silt ❑• Clay [] Peat E] Sandy Loam E] Clay Loam <br /> 1 . . , <br /> Hardpan ❑ -Adobe ❑ Fill Material.. .... .._ If yes, type......_..-•------------------- - <br /> (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc. must be placed on reverse side.) <br /> NEW INSTAL.ATION: [No septic tank or seepage pit permitted if public sewer is available within 200 feet,) ¢ <br /> PACKAGE TREATMENT [ ) SEPTIC TANK ------ Liquep .---:....-.... ............� <br /> [ ] Size.--�--. - ----�--- <br /> id Dth <br /> $ Capacity_..... ... TYPe---------- -- ---------Material-- ----- ---_-No. Compartments ---- •---- %J_ <br /> E <br /> Distance to nearest: Well---------------------------- ---- ---------Foundation------.... . ...... ......Prop. Line...... <br /> .-------.-----. <br /> LEACHING LINE [ ] No. of Lines ---------------------:.....Length of each line.............................. Total Length .. ....__-.--_---------------...-.:... <br /> D' Box, _­­r-Type Filter Material- --.- ...- Depth Filter Material------------------------------------------------------ ---_.... <br /> Distance to nearest: Well----.---------..............Foundation----.----------------.- --..Property Line...--------------.----.--- ----.:-. <br /> SEEPAGE PIT [ ) Depth .....Diameter----------------....Number------------------------•------- Rock Filled Yes ❑ No❑ <br /> ' Water Table,Depth---------------- ---- - -- - - -- --- --.-----------.- ------------------- <br /> Rock Size----- .... <br /> r <br /> Distance to nearest: Well------------------_----.-_. _-.----.---.--.Foundation.--_...............-....Prop. Line..-...-.---.---------- <br /> - � ----- <br /> REPAIR/ADDITION (Prev. Sanitation Permit <br /> i #------------------------------------- <br /> ---Dat_e.,�----<-�----Y---c-r---------- <br /> lTank'(Specify <br /> Requirements)_'.] <br /> .-- L <br /> Disposal Field (Specify Requiementsl....- . 4 --------------------------------------[ <br /> --------------- ------------------ <br /> ...................................... <br /> .... .__..___._.'.. . .............�...�...C...---..----------.-•------._.-....................................................... ..- -. <br /> #x'c {Draw,ezisting 6nd.reg0ired•addition on reverse side) <br /> I hereby,certiF that I have prepared this as lication and that the work will be done in accordance with San Joaquin County <br /> f . <br /> Ordinances, State Laws, and Rules arid' Regularikons,of the San Joaquin Local Health District, Home owner or licensed agents <br /> signature. certifies the following: <br /> "I certify that in the performance of the work•'for which this permit is issued, I shall not employ any person in such manner as <br /> t to become subject to W man' Compensation .laws of California.” <br /> Signed.--:-... .. f .................... <br /> Owner-: + «--- <br /> t <br /> B F , q J.� <br /> Y Title..............:.... '. <br /> { i Of other than,ow.ner_).,,, .' . <br /> fW DEPARTMENT USE ONLY , <br /> APPLICATION-ACCEPTED_BY! .. .�...� <br /> -.DATE -- 7777 <br /> DIVISION OF LAND NUMBtR T .................... -------- DATE---- ------- ------- ------ ........... <br /> ADDITIONAL„I~OMMENTS... -- ; --�-... ------------------------------- ........... . <br /> ------------ -- --- ------------ .- - ----- ----- -- ----------------------- <br /> -.. ........ 1 . <br /> ---------------------------- <br /> Finai InsRecfion by. .......... ------- ---------------------------Date_-. ._l ...... <br /> EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT __AY2 77 REV. 7/76 3M <br />